B&NES Primary Care Talking Therapies Service Referral Form
REFERRER DETAILS
Name of Referrer:
Address:
Organisation of Referrer:
Contact Number:
Date of Referral:
PATIENT DETAILS
Surname:
Gender:
NHS No.:
Forename(s):
Title:
Date of Birth:
Telephone Number
(mobile):
Can we leave a
message? Yes/No
Telephone Number
(home):
Can we leave a
message? Yes/No
Address:
GP Surgery:
Postcode:
Ethnicity:
Registered GP:
Current/Ex member of the army or reservists?
Yes – current / Yes – Ex / No
Please indicate if patient falls within these groups:
Disabilities:
Veteran / Has A Child Under Five / Pregnant
Long term conditions:
 Asthma
 Arthritis
 High blood pressure
 Crohn’s disease
 Cancer
 Chronic fatigue
 Chronic Kidney Disease
 Chronic Obstructive
Pulmonary Disease
 Chronic Pain
 Chronic Muscular Skeletal
 Chronic Pancreatitis










Coronary Heart Disease
Dementia
Insulin Dependent
Diabetes
Non Insulin Dependent
Diabetes
Eating Disorder
Epilepsy
Fibromyalgia
Hypertension
Irritable Bowel Syndrome
Multiple Sclerosis







Medically Unexplained
Conditions
Osteoporosis
Parkinson’s Disease
Severe Mental Health
Problems
Stroke and Transient
Ischaemic Attack
Thyroid Problem
Other (please specify):
REFERRAL INFORMATION
Reason for referral- PLEASE ATTACH CARE PLAN AND RISK ASSESSMENT :
Risk Information (Please provide any information about current or previous self-harm or suicide risks):
Previous contact with mental health services (please include any previous psychological therapy):
Any other relevant information (please include information concerning why the patient is unable to self-refer
and how best for us to contact the patient):
OFFICE USE
Date Received:
IAPTUS No.:
Please fax this form to 01225 362799 or email to awp.BPCTTSADMIN@nhs.net or post to: BANES Primary Care
Talking Therapies Service, Hillview Lodge, RUH, Bath, BA1 3NG.
Guidance for BPCTTS Referrals
The majority of individuals self-refer into our service, they can do this by contacting our service
directly on 01225 675150. We also offer a range of psycho-educational courses that can be booked
directly through our website, http://iapt-banes.awp.nhs.uk. If a patient is able to self-refer, please
provide them with a ‘working it out’ leaflet and encourage them to do so.
This referral form is for the minority of individuals who are unable to self-refer. Below is a list of
people that we typically work with, as well as our exclusion criteria. If you are making a referral to our
service, please ensure that the patient fits this criteria. If you are unsure you can contact our office
and ask to speak to a duty practitioner.
People We Typically Treat
•
People who fit within the traditional IAPT
framework – ie: mild/moderate anxiety
and/or depression AND
Exclusion Criteria
•
People who are at immediate or unstable
risk (no consolidated period of stability)
•
Main problem is an eating disorder and
their BMI (Body Mass Index) indicates any
risk
•
Moderate/Severe anxiety disorders
and/or depression
•
People under the care of Specialist Mental
Health Services
•
People experiencing a current psychotic
episode
•
People who have a diagnosis of
Personality Disorder or who may
experience similar symptoms and are
willing/able to engage in regular group
treatment
•
Anyone under 16 yrs
•
People who present a risk to staff
•
People using drugs or alcohol to a level
that would prevent them engaging in
treatment
•
People who are not stable enough to
engage in a talking therapy
•
People wanting long term therapy
•
People under the care of Specialist Mental
Health Services who are engaged in
specialist psychological treatment with
the Therapies Team
•
People who use drugs or alcohol
•
People with long term health conditions
•
People with psycho-sexual difficulties
•
Bereavement
•
Couples
•
Relational difficulties
•
Stress
•
Carers